Cultural humility and trauma-informed engagement

When working with communities, we may be working with people who have different backgrounds and life experiences from our own. It's therefore important that we apply cultural humility in our engagement. Some individuals and communities that we work with may have experienced traumatic or adverse life events, some of which may be related to health and social care, or research. By taking a trauma-informed approach to engagement, we can support our communities where this is the case and avoid the risk of potential re-traumatisation through our engagement.

What is cultural humility?

Watch the video about cultural humility from Psych Hub to find out about cultural humility and how it can support us in our work with different communities.

To be culturally humble is to be aware of social power imbalances and biases. It involves respecting other people's values, and ongoing reflection of how our own biases might impact on our interactions with other people.

More about cultural humility

Cultural Humility and Cultural Competency - what's the difference?

We may have heard use of the term Cultural Competency before. To be culturally competent is to learn about other cultures, control our biases and adapt our behaviours and communication styles accordingly. We use our knowledge about different groups and cultures to inform our behaviour. So how is this different from an approach of cultural humility?

Whereas cultural competence suggests that there is a level of knowledge that we can master about people from a certain community or background, cultural humility is about an approach rather than having a fixed set of knowledge. It is an ongoing process that involves self-reflection and continued learning.
Cultural humility is about being curious and open in how we approach conversations with people. This means that we are open to learning and increasing our awareness about a culture or community, but also to be curious about our own perceptions, biases and shortcomings.
It means that we are sensitive or become sensitive to power imbalances and that we are willing to do what we can to address them.
We listen to and take the lead from the people and communities we are working with.

How can we practice cultural humility when engaging with communities in research?

There are a number of steps we can take to incorporate cultural humility into our engagement with communities:

(i) Identify common ground

Prioritise creating social opportunities that allow you to get to know the community or group, including their ways of working, preferred use of language, and world views. Doing so also allows you to identify and build common ground, helping to build trust and reduce your own biases.

You can do this by inviting people for coffee, attending community events or spaces, drop-in sessions etc.

(ii) Let others lead the conversation and share their experience

Cultural competency has been criticised by some for emphasising the knowledge of the ‘majority’, i.e., the professional or organisation acquiring the knowledge they feel they need to understand a community.

Cultural humility emphasises the knowledge of individuals and groups from the community you are working with, and to focus on their experiences. By taking the time to listen and learn from the community in this way, about how the community works, norms and practices, we can truly understand and build our knowledge of how to include them in research/our work. It also means we can understand and respect the nuances and differences among individuals within a community, rather than risk seeing people as a homogenous group or monolith.

By doing so, we may find that culture has no impact on people’s perception of and relationship with health research or your organisation. Equally, we may learn that it affects this in a totally different way than we may have anticipated. It helps us to bust our assumptions.

(iii) Find training and learning opportunities

Just because a cultural competency approach has been criticised by some for not providing us with an accurate and holistic picture of a community, that doesn’t mean we can’t take steps to build up our knowledge. Finding training and learning opportunities is still helpful in providing us with background knowledge and considerations for how we approach and tailor our initial engagement.

We can then develop our approach further and in a more appropriate, personalised way as we get to know the people we engage with. For example, if we are going to be engaging with young trans people, we can attend trans awareness training to learn about some of the things we may need to consider and be aware of as we plan and approach our engagement.

(iv) Acknowledge and accept where we have got it wrong in the past

Practising cultural humility includes potentially learning about examples where we, our organisation, research, or health and social care systems may have failed groups and communities in the past. It is important that we are transparent and open about this history, that we acknowledge and accept where and why these examples are wrong, and that we are committed to doing better.

Trauma-informed engagement

Please note: This section contains details relating to trauma and abuse. Please take care whilst working through the information and resources as you feel you need to.

What is trauma?

Trauma results from an event, series of events, or set of circumstances that an individual experiences as either physically or emotionally harmful or life-threatening.
It has lasting adverse effects on the individual’s functioning and well-being.
A person may experience trauma at an individual, personal level, or community/group level (i.e. through a shared experience).
People may be re-traumatised, by re-experiencing thoughts, feelings or sensations experienced at the time of a traumatic event from their past.

Types of trauma

There are a range of different types of trauma we may come across in our engagement with communities:

Acute trauma - a single instance of fearing for one’s safety.
Chronic trauma - an ongoing perceived threat to one’s safety.
Complex trauma - when there is some combination of chronic and acute trauma.
Historic trauma - multigenerational and experienced by demographics, groups and families who have been impoverished, displaced, or otherwise oppressed over long periods of time.
Intergenerational trauma - emerging research suggests that individuals may pass down the effects of trauma to their descendants.

For examples of these different types of trauma, take a look at page 20 of NHS Education for Scotland's Transforming Psychological Trauma: A Knowledge and Skills Framework for the Scottish Workforce.

How might people have experienced trauma related to research?

Some people's experiences may have led to trauma that relates to the work we do in health and social care research. At an individual level, people may have had a poor experience with the NHS, social and/or public services. They or their community may have had poor or traumatic experiences with research in the past that may lead to mistrust and resistance to engaging with health and care professionals, and those working in research again.

At a community or intergenerational level, trauma may occur where a community has been poorly treated by research or healthcare systems in the past on a wider level. The group or community may experience intergenerational marginalisation and disenfranchisement from public services that lead to mistrust in health research.

Case study: The Syphilis Study at Tuskegee, USA

The following case study provides an example of a historic event that may trigger intergenerational or historic trauma for a group when it comes to health and care research.

In 1932, the USPHS, working with the Tuskegee Institute, began a study to record the natural history of syphilis. It was originally called the “Tuskegee Study of Untreated Syphilis in the Negro Male” (now referred to as the “USPHS Syphilis Study at Tuskegee”).
The study initially involved 600 Black men – 399 with syphilis, and 201 who did not have the disease. Participants’ informed consent was not collected. Participants were never told they had syphilis or that they were part of a study.
Researchers told the men they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anaemia, and fatigue. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance.
By 1943, penicillin was the treatment of choice for syphilis and became widely available. The participants in the study were not offered treatment when penicillin became available. Treatment was knowingly withheld for 40 years.
In 1972, an Associated Press story about the study was published. As a result, the Assistant Secretary for Health and Scientific Affairs appointed an Ad Hoc Advisory Panel to review the study. The advisory panel concluded that the study was “ethically unjustified”; that is, the “results [were] disproportionately meagre compared with known risks to human subjects involved.”
In October 1972, the panel advised stopping the study. A month later, the Assistant Secretary for Health and Scientific Affairs announced the end of the study.

Visit The Syphilis Study at Tuskegee website for more information about this case and its history.

How can we take a trauma-informed approach to engaging with communities in health and care research?

The US Substance Abuse and Mental Health Service Administration's (SAMSHA) Concept of Trauma and Guidance for a Trauma-Informed Approach, is widely used in health and social care to guide trauma-informed practices.

The guidance includes the four 'R's of trauma-informed practice, which we can apply to our work with communities in research. According to the four Rs, trauma-informed practice:

Realises - that trauma can affect individuals, communities, groups and organisations, and how it can do so. It appreciates how trauma can impact people’s experiences and their behaviours.
Recognises - the symptoms and signs of trauma, so that people in the organisation or system are able to recognise them.
Responds - to trauma by applying a trauma-informed approach to the organisation’s systems, policies, procedures, and practices. Staff change their language, behaviours and policies to take into consideration experiences of trauma. This can be achieved through the provision of staff training, and ensuring that policies (e.g. mission statements) promote a culture based on beliefs about resilience and recovery and a commitment to integrating the views and perspectives of people from these communities.
Resists re-traumatisation - of individuals and groups, both from within our staff and the communities/groups we work with. Staff are encouraged to learn how environments may trigger painful memories and re-traumatise communities/ individuals with trauma histories.

According to SAMSHA's guidance, a trauma-informed approach reflects adherence to six key principles rather than a prescribed set of practices or procedures. The application of these principles should be setting and community-specific.

Safety

Throughout the engagement process, staff and the community members they are working with feel physically and psychologically safe. Understanding safety as defined by those we are working with is a high priority. Some of the ways we can enact safety in our engagement include:

Establishing ways of working or ground rules for projects, workshops, meetings etc
Providing accessible and gender-inclusive spaces and toilets
Ongoing staff training and development

Trustworthiness and transparency

Decision-making and activities are conducted with transparency so that we build and maintain trust with individuals in the community, and within our organisation. Some of the ways we can enact trustworthiness and transparency in our engagement include:

Organisational and project policies and protocols that establish a trauma-informed approach
Keeping communities informed about decision-making and activities on an ongoing basis, even when there is a pause or quiet period in activities/decision-making

Peer support

The engagement process promotes and enables peer support and mutual self-help, as ways to establish safety and hope, build trust, and enhance collaboration. It supports people's own lived experiences to promote recovery and healing. One of the ways we can enact peer support in our engagement is:

Building opportunities for peer support and mutual self-help into the engagement process, for example, through a buddy system or opportunities for social connection among community group members.

Collaboration and mutuality

Importance is placed on partnership and levelling power differences between the organisation and members of the community. This principle involves the meaningful sharing of power and decision-making. Some of the ways we can enact collaboration and mutuality in our engagement include:

Community organisations and individuals as co-applicants or co-leads on engagement or research projects
Working across sectors with organisations that work within the community and provide trauma-informed support, such as NHS services, and mental health and wellbeing organisations.
Co-designing and co-producing your engagement or project

Empowerment, choice, voice

Individuals’ strengths and experiences are recognised and built upon. The organisation fosters a belief in the primacy of the community and the ability of communities to heal and promote recovery from trauma. The organisation understands existing power differentials and the ways in which community members have historically been diminished in voice and choice.

They are supported in making decisions, choices and goal setting, and in cultivating self-advocacy skills. Staff are also empowered to do their work, and need to feel safe as much as the community members they are working with. Some of the ways we can enact empowerment, choice and voice in our engagement include:

Making sure community members are involved in engagement governance and decision-making (e.g. advisory group or co-leads in project activities)
Participatory action research, community member-led activities and co-design as part of the engagement

Culture, history, gender

The engagement actively moves past cultural stereotypes and biases and incorporates policies, protocols and processes that are responsive to the cultural needs of the community or individual(s) you are working with. It recognises and addresses historical trauma. This principle is essentially about practising cultural humility and includes acknowledging and accepting where health and care research has contributed to the traumatisation of a community or individuals in a community in the past. Some of the ways we can enact culture, history and gender in our engagement include:

Building staff knowledge of a group/culture’s history within health and care research through open dialogue with the community, and taking action in response

Further resources